177

The anaesthetist plays an important role in the

multidisciplinary team management of patients
with major burns which should occur in spe-
cialised regional units. All anaesthetists need to be
familiar with the principles of anaesthesia for
these patients as they may be required to care for
a major burn in an emergency or to provide care
for minor burns outside the regional centres. Initial
resuscitation and stabilisation has already been
covered previously in this journal (see key refer-
ences). This article deals with the preparation of
burns patients for theatre and peri-operative anaes-
thetic management.
Pathophysiological changes
Airway
The upper airway may be compromised. Acutely,
thermal injury leads to progressive swelling of the
soft tissues and potential airway obstruction. This
swelling may persist for several days and may be
complicated by scarring and contractures. The
lower airway is rarely burned by exposure to heat
unless substances with a very high specific heat
capacity are inhaled, such as superheated steam.
The lower airway is injured by inhalation of
smoke, leading to inflammation, mucosal slough-
ing, airway irritability and activation of the sys-
temic inflammatory response syndrome (SIRS).
The acute consequences of this in severe smoke
inhalation include development of excess pul-
monary secretions, bronchospasm and the acute
respiratory distress syndrome (ARDS).
The constituents of the smoke also determine
the degree of airway injury and consequent hyp-
oxaemia. For example, products of combustion of
certain household commodities such as PVC,
Teflon and polyurethane are particularly toxic as
they contain chemicals such as hydrogen chlo-
ride, phosgene, hydrogen cyanide and isocyanate.
In addition to the hypoxaemia resulting from air-
way damage, many of these compounds have
toxic effects on the cellular respiratory chain, fur-
ther aggravating the hypoxaemia. Even when the
effects have resolved, increased airway reactivity
may persist for several months after the injury.
Circulation
Burns have a direct local effect on blood vessel
integrity and function; there are also widespread
effects on capillary permeability and blood flow.
In the area of full thickness burns, vessels will be
thrombosed or destroyed. There is a localised
increase in tissue capillary permeability as a
direct result of thermal injury. In addition, activa-
tion of the systemic inflammatory response caus-
es a widespread increase in vascular permeability
with generalised oedema. Mediators involved in
the vascular response to burn injury include hist-
amine, prostaglandins PGE
2
and PGI
2
, leuko-
trienes LB
4
and LD
2
, thromboxane A
2
, inter-
leukin-6, catecholamines, oxygen free radicals,
platelet aggregation factor, angiotensin II and
vasopressin. Although bradykinin and serotonin
levels are increased in the immediate post-burn
period, their antagonists have not been demon-
strated to reduce consequent oedema. Inhalation
injury, hypo-albuminaemia and sepsis exacerbate
this increase in vascular permeability. Patients
require fluid resuscitation to allow for these loss-
es but invariably, in the early stages after the burn,
patients have relative hypovolaemia and
decreased tissue perfusion. Later, the patient
develops a cardiovascular picture of high cardiac
output and vasodilatation due to sepsis or SIRS.
As a result of the cardiovascular changes, there
may be impaired renal perfusion and function.
Muscle
The muscle underlying any burn may be dam-
aged, but this is much more likely following elec-
trocution which may cause myoglobin release
and further renal damage. More widespread
Anaesthetic management for
burns patients
Roland G Black MRCP FRCA
John Kinsella FRCA
British Journal of Anaesthesia | CEPD Reviews | Volume 1 Number 6 2001
The Board of Management and Trustees of the British Journal of Anaesthesia 2001
Key points
Anaesthesia is required
on numerous occasions
following a major burn
Anaesthetists play a
major role in resuscita-
tion, intensive care and
analgesia
Sepsis, systemic inflam-
matory response syn-
drome, altered pharma-
cokinetic compartments
and receptor population
changes make response
to drugs unpredictable
Hyperkalaemia following
succinylcholine, resis-
tance to non-depolarising
muscle relaxants and air-
way compromise lead to
difficulty with airway
management
Vascular access, pro-
longed procedures, blood
loss and temperature
homeostasis are major
challenges
Roland G Black MRCP FRCA
Clinical Research Fellow
University Department of
Anaesthesia
Glasgow Royal Infirmary
10 Alexandra Parade
Glasgow G31 2ER
John Kinsella FRCA
Consultant in Anaesthesia and
Intensive Care
University Department of
Anaesthesia
Glasgow Royal Infirmary
10 Alexandra Parade
Glasgow G31 2ER
Anaesthetic management for burns patients
178
British Journal of Anaesthesia | CEPD Reviews | Volume 1 Number 6 2001
muscle conformational changes gradually develop after injury
with proliferation of acetylcholine receptors which has conse-
quences for neuromuscular junction function.
Myocardial depression occurs as a result of circulating factors
which have been shown to have direct negative inotropic effects on
in vitro myocardial preparations. The exact mechanism of action is
unknown, but free radical scavengers such as super-oxide dismu-
tase have been shown to increase myocardial contractility follow-
ing burn injury, suggesting oxygen free radicals may play a role.
Following an electrical burn, cardiac muscle may be damaged,
increasing the risk of myocardial dysfunction and dysrhythmias.
Pharmacology
Large fluid shifts, changes in compartment sizes and increase in
metabolic rate alter the pharmacokinetics of many drugs. Low
albumin leads to an increased free fraction of acidic drugs such as
sulphonylureas or anticonvulsants. Raised fibrinogen and
1
acid
glycoprotein will reduce the free fraction of basic drugs (e.g. local
anaesthetics, propranolol and muscle relaxants). As most laborato-
ries measure total drug concentrations rather than free fractions,
serum concentrations may be misleading. These effects, in combi-
nation with altered receptor populations and pharmacodynamics,
significantly alter the dose requirements and effects of many
anaesthetic drugs.
Requirements for anaesthesia
The anaesthetist has a number of skills that may be required in the
care of the burn patient. In the initial resuscitation, airway assess-
ment, intubation, vascular access, fluid resuscitation, administra-
tion of analgesia and intensive care may all be required. General
anaesthesia may be required for intubation, emergency tracheosto-
my, escharotomy and urgent surgery for other injuries.
There is an increasing trend towards early definitive surgery to
the burn wound, both as a means of improving cosmetic result and
as a way of removing necrotic tissue, thereby reducing the on-
going stimulus for SIRS. As a consequence, patients may require
anaesthesia as soon as they are fully resuscitated. From this point,
the patient may require multiple procedures over many days and
weeks. Subsequently, reconstructive surgery may be performed
over several years.
Choice of agents
Induction and maintenance of anaesthesia
Ketamine 12 mg kg
1
has traditionally been advocated as the
induction anaesthetic of choice. The combination of its analgesic
effects, sympathetic stimulation and maintenance of airway reflex-
es would seem to make it the ideal agent. However, it is associated
with unpleasant emergence and, with the advent of shorter acting
anaesthetics such as propofol, ketamine has been largely super-
seded. Propofol 2 mg kg
1
with alfentanil 100 g kg
1
has been
described as the induction dose of a TIVAtechnique. The choice of
volatile agent does not seem to influence outcome from burns
surgery.
Analgesia
Analgesic requirements in the initial phase vary. The patients per-
ception of pain may be altered by reduced conscious level, alcohol,
drugs, hypoxaemia or hypotension. The use of simple measures
such as immobilisation, cooling or covering the burn may be effec-
tive. Entonox can be used but only if the patients oxygen require-
ments are less than 50%. Opioids are the mainstay of pain man-
agement, but should be titrated intravenously rather than adminis-
tered as boluses subcutaneously or intramuscularly (absorption
from both of these routes is unpredictable).
After the initial resuscitation phase, pain can be divided into
background and procedural. The appropriate initial management of
background pain should usually be with intravenous opioids. The
successful use of opioid infusions and patient-controlled analgesia
with morphine have been described in adults and children. Later,
when feeding is established, background pain can be managed with
oral analgesics. Again, requirements vary, so the doses should be
titrated for each patient and, as tolerance develops quickly, dosing
schedules should be reviewed regularly. Non-steroidal anti-inflam-
matory drugs should be used with caution as these patients are
already predisposed to renal dysfunction and gastric ulceration.
The use of agonist-antagonist and partial agonist opioids has been
described. However, their use has not become established because
of limited efficacy and undesirable side effects.
Procedural pain, such as that associated with debridement or
with dressing changes, can be severe and require intravenous opi-
oids. Again, dose requirements vary widely, depending on the indi-
vidual and on factors such as position, extent and age of the burn
and the presence or absence of local infection. Opioids should be
titrated to effect. The use of a target-controlled infusion of alfen-
tanil to provide analgesia for dressing changes has been described.
In our study, high target concentrations (up to 290 ng ml
1
) and
total doses (up to 10.7 mg) of alfentanil were required; apnoea or
desaturation did not occur.
Neuromuscular blocking drugs
The exaggerated hyperkalaemic response seen with succinyl-
choline is thought to be due to extrajunctional migration of
Anaesthetic management for burns patients
British Journal of Anaesthesia | CEPD Reviews | Volume 1 Number 6 2001
179
acetylcholine receptors. The earliest described post-burn hyper-
kalaemic response is at 9 days and the earliest cardiac arrest at 21
days. The exaggerated response persists for up to 10 weeks, though
some argue that succinylcholine should be avoided for 1 year post-
injury.
Burns patients also demonstrate a resistance to non-depolarising
muscle blockade with the ED
50
of vecuronium in one study being
3 times that of controls. This resistance develops by 1 week and
usually persists for 8 weeks; though resistance to metocurine has
been described 463 days post-burn. It can only be partially
explained by pharmacokinetic mechanisms; acetylcholine receptor
proliferation may be responsible for some of this resistance.
Other drugs
Epinephrine solutions ranging in concentration from 1:1000 to
1:500,000 are applied topically or infiltrated subcutaneously to
reduce blood loss at excision and donor sites. Resting plasma cat-
echolamine concentrations are elevated post-burn, but the systemic
absorption of epinephrine does not seem to be associated with sig-
nificant cardiovascular side effects.
Local anaesthetics applied topically are used for burn excision
and donor site analgesia. The use of EMLA alone has been
described for graft harvest in debilitated patients with burns of
< 10% total body surface area. Lidocaine 2% sprayed onto the har-
vest site has been shown to reduce opioid requirements in the 24 h
post-surgery when compared with a placebo or 0.5% bupivacaine
group. Toxic concentrations were not seen in either the lidocaine or
bupivacaine group. Increased concentrations of
1
-acid glycopro-
tein seen post-burn would be protective.
Burns patients are particularly prone to infection due to the loss
of the skins barrier function. Randomised controlled trials have
failed to show any benefit of prophylactic antibiotics and their use
merely promotes resistant strains of bacteria. Dose requirements of
aminoglycosides, cephalosporins and -lactams are altered due to
their increased clearance. Plasma concentrations should be moni-
tored and doses adjusted accordingly.
Monitoring
Monitoring should routinely include ECG, arterial haemoglo-
bin oxygen saturation, respiratory gas analysis, central tem-
perature, urine output and blood pressure. Some of the diffi-
culties relating to monitoring are summarised in Table 1.
Pre-operative preparation and conduct of
anaesthesia
Fasting
Burns patients are hypermetabolic. Repeated fasting required
for surgical procedures may interfere with nutritional goals
with associated increase in wound infection rate and muscle
catabolism. It has been shown that patients only receive 15%
of their nutritional needs on the day of surgery with a pre-
operative fast of 4 h and 30% if the fasting time is reduced to
1 h. No aspiration was seen in either group suggesting that
fasting guidelines should be modified in burns patients.
Intubated patients can be fed intra-operatively.
Transport to theatre
There is considerable debate regarding the location of the theatre
dealing with burns. A theatre in the burns unit minimizes patient
transport distances, but has the risks associated with an isolated
site. On the other hand, if surgery is taking place in the main
theatre suite, there may be logistical issues concerning the
Table 1 Problems encountered with routine monitoring in burns patients
Monitor Difficulty in burns patients Potential solution
ECG Gel electrodes may not pick up ECG through damaged skin Skin staples or subcutaneous needles attached to crocodile clips will give
a good signal
Lead placement, avoiding operative field Careful placement, avoiding areas to be debrided or harvest sites, e.g. limb leads
SaO
2
Peripheral burns or vasoconstriction may lead to difficulty Use of alternate sites such as lips or tongue has been described
with trace
Carboxyhaemoglobin may give spurious results Use arterial gas analysis and carboxyhaemoglobin measurements if there
is concern
Blood pressure Invasive versus non invasive measurement Invasive blood pressure measurement carries the same risks as normal patients,
siting of an arterial cannula may be difficult. However, waveform provides
additional information and an arterial line facilitates arterial sampling
End-tidal CO
2
Because of increased dead-space in inhalation injury, Arterial gas analysis should be used to monitor ventilatory settings
end-tidal CO
2
may not reflect PaCO
2
CVP Access sites may be difficult Consider long lines
Increased risk of infection and caval venous system thrombosis Needs to be balanced against the potential benefits
Swan-Ganz As with CVP lines
catheters
Anaesthetic management for burns patients
180
British Journal of Anaesthesia | CEPD Reviews | Volume 1 Number 6 2001
transport of very unstable patients. Patients receiving inten-
sive care should be transferred with full mobile facilities irre-
spective of the location of the operating theatre.
Airway
Concerns about airway patency have been referred to above
and should have been addressed at the initial resuscitation
phase. However, oedema may be present even in the absence
of overt airway injury. The anaesthetist should, therefore, be
mindful of any airway compromise and, if there is any doubt,
an awake fibre-optic intubation or gaseous induction should
be carried out. Theoretically, because of the increased cardiac
output occurring post-burn, a gas induction should take longer
than usual. However, in practice, this is not seen. Intubation
secures the airway and allows bronchoscopic evaluation of air-
way injury. Patients already intubated should have the tube posi-
tion checked and secured prior to the commencement of surgery.
Concerns about airway patency in the later stages of burn injury
are related to fibrosis and contractures making airway manipu-
lation and intubation difficult or impossible. Fibre-optic intuba-
tion may be required. The successful use of the laryngeal mask
airway has been described in both adults and children.
Patients with significant airway injury or a large burn will
need artificial ventilation in theatre. They require a greater than
normal minute volume as the basal metabolic rate is elevated
and gas exchange may be compromised. Because of increased
dead-space, end-tidal CO
2
measurements may not reflect arteri-
al CO
2
tension and arterial gas analysis may be indicated. An
intensive care ventilator may be required to deliver adequate
minute ventilation and provide PEEP and advanced ventilatory
modes. Following major burns, smoke inhalation and the subse-
quent development of ARDS, these patients may be very depen-
dent on PEEP. If there has been extensive blood loss and
replacement, delayed extubation may be preferred.
Fluid and temperature homeostasis
Apatient should only be taken to theatre when fluid resuscitation
is adequate (as evidenced by haemodynamic parameters and urine
output) and in the absence of hypothermia. Wound debridement
involves significant blood loss. It has been estimated that for every
1% body surface excised, 34% of the circulating blood volume
may be lost. There should be adequate availability of red cells and
clotting factors. Due to damage of the natural skin barrier, evapo-
rative losses are raised, further increasing fluid requirements. Good
wide bore i.v. access is essential. Depending on the size and posi-
tion of the burn, traditional i.v. access sites may be unavailable and
unusual peripheral venous sites or central venous access are fre-
quently required. Care of the available veins is a priority and all i.v.
access should be performed by experienced personnel.
The combination of large fluid requirements and extensive
patient exposure predisposes to intra-operative hypothermia which
has undesirable effects on coagulation, cardiorespiratory function
and drug handling. It has been shown to be associated with worse
outcome in burns patients and should, therefore, be avoided.
Central temperature should be measured and maintained and there
should be adequate provision of warmed rapid infusion systems. If
possible, forced warm air blankets should be used but these may
be of limited efficacy due to the degree of patient exposure
required. It is important that the theatre environment is at a ther-
moneutral temperature (about 30C for these patients), although
this may be uncomfortable for theatre staff.
In the reconstructive phase of surgery, the viability of skin grafts
and tissue flaps is improved if the patient is warm and hyperdy-
namic. Careful attention should be paid to fluid status and mainte-
nance of temperature using the measures outlined above.
Patient position
In both the acute and reconstructive phase of burn surgery, metic-
ulous attention should be given to patient positioning as many
procedures are prolonged. Patients are often required to be placed
in the prone position or moved intra-operatively.
Regional anaesthesia
Despite being of use in minor burns, regional anaesthesia is not
beneficial in major burns. The reasons for this are: (i) it can be
difficult to block a sufficient area; (ii) vasodilatation associated
with epidural blockade accentuates the hypotensive effects of
blood loss during surgery; and (iii) the loss of the normal skin
barrier leads to transient intra-operative bacteraemia which may
colonise an epidural catheter.
Key references
Hilton PJ, Hepp M.The immediate care of the burned patient. BJA CEPD Rev
2001; 1: 1136
Judkins K. Burns treatment in the 21st century: a challenge for British anaes-
thesia. Anaesthesia 1999; 54: 11315
Kinsella J, Rae C. Burn pain. Ballires Clin Anaesthesiol 1997; 11: 45972
Lingnau W, Woodson LC, Nichols RJ, Prough DS. Anaesthesia for burned
patients. In: Herndon DN. (ed) Total Burn Care. London: Saunders, 1996;
14858
Whelan E. Drug disposition and action in the burned patient. Ballires Clin
Anaesthesiol 1997; 11: 42740
Yowler CJ. Recent advances in burn care. Curr Opin Anaesth 2001; 14: 2515
See multiple choice questions 111113.